Articles tagged as "Global / multilateral and bilateral responses"

The do’s and don’ts for human resource strategies as external financing makes its exit: lessons from Namibia

Confronting 'scale-down': Assessing Namibia's human resource strategies in the context of decreased HIV/AIDS funding.

Cairney LI, Kapilashrami A. Glob Public Health. 2014 Jan-Feb;9(1-2):198-209. doi: 10.1080/17441692.2014.881525. Epub 2014 Feb 6.

In Namibia, support through the Global Fund and President’s Emergency Plan for AIDS Relief has facilitated an increase in access to HIV and AIDS services over the past 10 years. In collaboration with the Namibian government, these institutions have enabled the rapid scale-up of prevention, treatment and care services. Inadequate human resources capacity in the public sector was cited as a key challenge to initial scale-up; and a substantial portion of donor funding has gone towards the recruitment of new health workers. However, a recent scale-down of donor funding to the Namibian health sector has taken place, despite the country’s high HIV and AIDS burden. With a specific focus on human resources, this paper examines the extent to which management processes that were adopted at scale-up have proven sustainable in the context of scale-down. Drawing on data from 43 semi-structured interviews, we argue that human resources planning and management decisions made at the onset of the country’s relationship with the two institutions appear to be primarily driven by the demands of rapid scale-up and counter-productive to the sustainability of interventions.

Abstract access 

Editor’s notes: Some countries graduate to higher income categories and become ineligible for funding from major donors, such as the Global Fund and PEPFAR. As this happens, it is increasingly important to draw lessons on how to manage this transition from international to domestic financing and ownership. Using the case of human resource management, this study underscores the need to establish exit strategies early on. It also emphasises the need to ensure the integration of management processes within government systems. These are deemed necessary if high service coverage rates are to be maintained. The case study documents how additional health professionals were recruited at higher salaries than government salaries through a parallel recruitment system.  This was done in order to meet the needs of service scale-up. However, that approach led to an unsustainable situation. Sudden salary cuts jeopardised service continuity and the expectation that these staff would be absorbed on to the government payroll. There appears to be a trade-off between certain structures to enable rapid scale-up and programme sustainability. These ought to be planned for at an early stage of funding partnerships.   

Africa
Namibia
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Sustaining HIV responses in a post-Global Fund era: lessons from Peru

After the Global Fund: Who can sustain the HIV/AIDS response in Peru and how?

Amaya AB, Caceres CF, Spicer N, Balabanova D. Glob Public Health. 2014 Jan-Feb;9(1-2):176-97. doi: 10.1080/17441692.2013.878957. Epub 2014 Feb 5.

Peru has received around $70 million from the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund). Recent economic growth resulted in grant ineligibility, enabling greater government funding, yet doubts remain concerning programme continuity. This study examines the transition from Global Fund support to increasing national HIV/AIDS funding in Peru (2004–2012) by analysing actor roles, motivations and effects on policies, identifying recommendations to inform decision-makers on priority areas. A conceptual framework, which informed data collection, was developed. Thirty-five in-depth interviews were conducted from October to December 2011 in Lima, Peru, among key stakeholders involved in HIV/AIDS work. Findings show that Global Fund involvement led to important breakthroughs in the HIV/AIDS response, primarily concerning treatment access, focus on vulnerable populations and development of a coordination body. Nevertheless, reliance on Global Fund financing for prevention activities via non-governmental organisations, compounded by lack of government direction and weak regional governance, diluted power and caused role uncertainty. Strengthening government and regional capacity and fostering accountability mechanisms will facilitate an effective transition to government-led financing. Only then can achievements gained from the Global Fund presence be maintained, providing lessons for countries seeking to sustain programmes following donor exit.

Abstract access 

Editor’s notes: Some countries graduate to higher income categories and become ineligible for funding from major donors, such as the Global Fund and PEPFAR. As this happens,it is important to learn how the transition from international to domestic financing and ownership is managed. This study complements the previous paper, and documents the case of Peru and the impending exit of Global Fund support. The national and regional coordination bodies initially created for inter-sectoral dialogue and planning around Global Fund grant applications appear to be enabling factors for programme sustainability. As Peru started aligning Global Fund HIV activities with local priorities early on, this has helped set the stage for a smoother integration of such efforts in the national response. The authors highlight, however, that the predominant role of NGOs as implementers of prevention activities could become a limiting factor for sustainability.  This is so, given that they will become dependent on government funding, and may have a weakened ability to be able to hold the government to account. 

Latin America
Peru
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Gender, structural determinants and vulnerability

A critical analysis of Peru's HIV grant proposals to the Global Fund. 

Cáceres CF, Amaya AB, Sandoval C, Valverde R. Glob Public Health. 2013 Dec;8(10):1123-37. doi: 10.1080/17441692.2013.861859

Peru has applied to six of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) rounds for funding, achieving success on four occasions. The process of proposal development has, however, been criticised, especially concerning the use of evidence, relevance/consistency and performance indicators. We aimed to analyse the Peruvian Global Fund proposals according to those dimensions, providing feedback to improve future local efforts and inform global discussions around Global Fund procedures. We analysed the content of four HIV-focused proposals (rounds 2, 5, 6 and 8) regarding epidemic context, needs identification and prioritisation and monitoring and evaluation systems. Peruvian proposals submitted after round 1 were described as resulting from collaborative inputs involving formerly unrepresented sectors, principally 'vulnerable populations'. However, difficulties arose regarding the amount and quality of evidence about the epidemiological context; limited consideration of social determinants of the epidemic; lack of theory-driven interventions, and little synergy across projects and the inclusion of weak monitoring and evaluation systems, with poor indicators and measurement procedures. Prioritising the development of analytical and technical skills to generate Global Fund proposals would enhance the country's capacity to produce and utilise evidence, improve the technical-political interface, strengthen information systems and lead to more informed decision making and accountability.

Abstract access 

Editor’s notes: This is a useful paper that dissects one country’s Global Fund proposals over 10 years (2002-2012) to assess the use of evidence, the consistency and appropriateness of proposed activities and the adequacy of its monitoring and evaluation framework. Although only one country, Peru, is scrutinised in this paper, many of the findings will be relevant to the development and implementation of Global Fund proposals in other countries.

It was encouraging to learn that the use of evidence improved over time. However the lack of appropriate surveillance data meant that proposals were not always found to be evidence-based. The paper highlights in particular the need to use epidemiological evidence that is related to specific population sub-categories to address “vulnerability” and ensure that interventions are effectively targeted.

Consistency and continuity across proposals was sometimes lacking, possibly reflecting the Global Fund’s mechanistic funding process via “rounds”. The paper notes that at times, programmes could appear to be a juxtaposition of activities rather than a well thought out comprehensive strategy. It would be interesting to see whether the Global Fund's new funding model based on the national HIV/AIDS strategy in the future leads to a more continuous and consistent flow of activities.

Another key point in the paper is the inadequacy of the proposals’ monitoring and evaluation (M&E) framework to monitor grants and evaluate results. As the paper notes, the information system will need to be strengthened for the M&E to deliver a more evidence based strategy.

Latin America
Peru
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Does global procurement and price negotiation through the Global Fund reduce HIV commodity costs?

Trends in procurement costs for HIV commodities: a seven-year retrospective analysis of Global Fund data across 125 countries. 

Wafula F, Agweyu A, Macintyre K. J Acquir Immune Defic Syndr. 2013 Nov 20. [Epub ahead of print]

Background: Nearly 40% of Global Fund money goes towards procurement. However, no analyses have been published to show how costs vary across regions and time, despite the availability of procurement data collected through the Global Fund's price and quality reporting (PQR) system.

Methodology: We analyzed data for the three most widely procured commodities for the prevention, diagnosis and treatment of HIV. These were male condoms, HIV rapid tests, and the ARV combination of lamivudine/nevirapine/zidovudine. The compared costs, first across time (2005-2012), then across regions, and finally, between individual procurement reported through the PQR and pooled procurement reported through the Global Fund's voluntary pooled procurement (VPP) system. All costs were adjusted for inflation and reported in US dollars.

Key findings: There were 2 337 entries from 578 grants in 125 countries. The procurement cost for the ARV dropped substantially over the period, whereas those for condoms and HIV tests remained relatively stable. None of the commodity prices increased. Regional variations were pronounced for HIV tests, but minimal for condoms and the ARV. The unit cost for the three-table ARV combination, for instance, varied between US$0.15 and US$0.23 in South Asia and the Eastern Europe/Central Asia regions respectively, compared to a range of $0.23 (South Asia) - $1.50 (Eastern Europe/Central Asia) for a single diagnostic test. Pooled procurement lowered costs for condoms, but not the other commodities.

Conclusion: We showed how global procurement costs vary by region and time. Such analyses should be done more often to identify and correct market insufficiencies.

Abstract access 

Editor’s notes: With the flatlining of HIV resources, it is important that HIV investments are optimally used, and achieve good value for money. The Global Fund has played a major role in financing HIV programmes, with over a half of the US$23 billion given since 2002 going to HIV. A large proportion of Global Fund grants go towards the procurement of pharmaceuticals and other health products. The global fund uses its (and partners, such as PEPFAR and Clinton Health Access Initiative) bulk purchasing power to negotiate lower commodity prices for countries.  It has also set up systems to support countries to negotiate costs and identify cheap suppliers. This paper uses information from the Global Fund across time and recipient countries, to explore how costs of 3 HIV related commodities have changed over time, and/or vary regionally. The trends observed reflect a variety of market factors, and the increasingly global nature of commodity markets. The reduction in antiretroviral therapy (ART) costs are likely to result from increased competition across suppliers, the move to generic drug use, and the joint negotiation in cost reductions, and there may be scope for further price reductions. In contrast, the limited variation in costs for HIV tests and male condoms suggest that markets for these commodities have stabilized, leaving limited room for negotiation. 

Africa, Asia, Europe, Latin America, Oceania
South Africa
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Modelling finds early treatment of HIV discordant couples is cost-effective in India and South Africa

Cost-effectiveness of HIV Treatment as Prevention in Serodiscordant Couples.

Walensky RP, Ross EL, Kumarasamy N, Wood R, Noubary F, Paltiel AD, Nakamura YM, Godbole SV, Panchia R, Sanne I, Weinstein MC, Losina E, Mayer KH, Chen YQ,Wang L, McCauley M, Gamble T, Seage GR 3rd, Cohen MS, Freedberg KA. N Engl J Med. 2013 Oct 31;369(18):1715-25. doi: 10.1056/NEJMsa1214720.

Background: The cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons.

Methods: For HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART.

Results: In South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modelled assumptions in the two countries.

Conclusions:  In South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings.

Abstract access

Editor’s notes: The HPTN 052 found that antiretroviral therapy (ART) can prevent onward HIV transmission. With this finding, countries in the North and South are faced with optimizing treatment protocols, for the direct clinical benefit of ART, and its impact on national HIV epidemics.  Walensky et al. draw on data from this clinical trial in India and South Africa to model the short (5 year) and long (cohort lifetime) term cost-effectiveness. The main study models cost-effectiveness with trial based parameters i.e., cd4+ count at presentation, virological suppression and failure, loss to follow up and transmission rates. They also estimate cost-effectiveness in routine care setting and worst case scenario to consider the robustness of findings.  In contrast to many model projections which find ART for prevention more cost effective over longer time frames, Walensky’s projections show very immediate (5 year) reductions in transmission and treatment costs attributable to preventing opportunistic infections.  In South Africa this results in short term cost-saving; as the cost of treating these are relatively lower in India, this is highly cost effective, albeit not cost saving. In the longer term their model shows that many of these transmissions are delayed rather than avoided altogether: in South Africa the 5 year reduction in transmission is 69% versus 13% over the cohort lifetime.  Evaluated against per capita GDP in each country, treatment as prevention is shown to be cost-effective in both settings.  These results are sensitive to retention in care and effective virological suppression, though would not change policy recommendations. However it does highlight critical role of both the health system and patients in reaping the optimal prevention benefits of treatment. 

Africa, Asia
India, South Africa
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‘Public’ and ‘hidden’ transcripts of the Global Fund in India

Transforming governance or reinforcing hierarchies and competition: examining the public and hidden transcripts of the Global Fund and HIV in India.

Kapilashrami A, McPake B. Health Policy Plan. 2013 Sep;28(6):626-35. doi: 10.1093/heapol/czs102. Epub 2012 Nov 11.

Global health initiatives (GHIs) have gained prominence as innovative and effective policy mechanisms to tackle global health priorities. More recent literature reveals governance-related challenges and their unintended health system effects. Much less attention is received by the relationship between these mechanisms, the ideas that underpin them and the country-level practices they generate. The Global Fund has leveraged significant funding and taken a lead in harmonizing disparate efforts to control HIV/AIDS. Its growing influence in recipient countries makes it a useful case to examine this relationship and evaluate the extent to which the dominant public discourse on Global Fund departs from the hidden resistances and conflicts in its operation. Drawing on insights from ethnographic fieldwork and 70 interviews with multiple stakeholders, this article aims to better understand and reveal the public and the hidden transcript of the Global Fund and its activities in India. We argue that while its public transcript abdicates its role in country-level operations, a critical ethnographic examination of the organization and governance of the Fund in India reveals a contrasting scenario. Its organizing principles prompt diverse actors with conflicting agendas to come together in response to the availability of funds. Multiple and discrete projects emerge, each leveraging control and resources and acting as conduits of power. We examine how management of HIV is punctuated with conflicts of power and interests in a competitive environment set off by the Fund protocol and discuss its system-wide effects. The findings also underscore the need for similar ethnographic research on the financing and policy-making architecture of GHIs.

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Editor’s notes: The paper presents results of a study on the implementation of the Global Fund fourth round HIV/AIDS grant in five states of India. It draws on Scott’s (1992) distinction between ‘dominant public transcripts’ –  official and documented statements describing principles, structures and activities - and ‘hidden transcripts’ meaning the unofficial practices and realities that are rarely acknowledged in official documents. While such a distinction is not new in the social sciences, for instance public and private accounts of experiences of health and illness are often contrasted, this framing provides a useful way to distinguish official rhetoric from interviewees’ discourses and observation of day-to-day practices of decision making and implementation. The study took an ethnographic approach between 2007 and 2009 to articulate these ‘hidden transcripts’ consisting of observations of meetings, document review and 70 ‘in-depth’ stakeholder interviews.

The paper reports on several aspects of the Indian experience that reinforce findings from previous studies of the effects of Global Fund HIV/AIDS programmes in other countries. These include limited involvement of local civil society organisations in grant application processes. Instead the application process was dominated by government, bilateral and multilateral agencies and large national/international civil society organisations. Country Coordination Mechanism (CCM) activities were confined to applying for grants rather than overseeing programme implementation. Demanding reporting requirements strained an already weak health system, created competition between implementers and impacted negatively on the continuity of interventions. The paper concludes that while the Global Fund claims to be a financial mechanism for country-driven programmes, its structures, rules and conditions create a highly regulating environment for programme implementation. 

Asia
India
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Patient expenditures for TB care are impoverishing and may prevent access to care

Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage.

Ukwaja KN, Alobu I, Abimbola S, Hopewell PC. Infect Dis Poverty. 2013 Sep17;2(1):21. [Epub ahead of print]

Background: Studies on costs incurred by patients for tuberculosis (TB) care are limited as these costs are reported as averages, and the economic impact of the costs is estimated based on average patient/household incomes. Average expenditures do not represent the poor because they spend less on treatment compared to other economic groups. Thus, the extent to which TB expenditures risk sending households into, or further into, poverty and its determinants, is unknown. We assessed the incidence and determinants of household catastrophic payments for TB care in rural Nigeria.

Methods: Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health facilities in Ebonyi State, Nigeria. Using household direct costs and income data, we analyzed the incidence of household catastrophic payments using, as thresholds, the traditional >10% of household income and the >=40% of non-food income, as recommended by the World Health Organization. We used logistic regression analysis to identify the determinants of catastrophic payments.

Results: Average direct household costs for TB were US$157 or 14% of average annual incomes. The incidence of catastrophic payment was 44%; with 69% and 15% of the poorest and richest household income-quartiles experiencing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age >40 years (adjusted odds ratio [aOR] 3.9; 95% confidence interval [CI], 2.0, 7.8), male gender (aOR 3.0; CI 1.8, 5.2), urban residence (aOR 3.8; CI 1.9, 7.7), formal education (aOR 4.7; CI 2.5, 8.9), care at a private facility (aOR 2.9; 1.5, 5.9), poor household (aOR 6.7; CI 3.7, 12), household where the patient is the primary earner (aOR 3.8; CI 2.2, 6.6]), and HIV co-infection (aOR 3.1; CI 1.7, 5.6).

Conclusions: Current cost-lowering strategies are not enough to prevent households from incurring catastrophic out-of-pocket payments for TB care. Financial and social protection interventions are needed for identified at-risk groups, and community-level interventions may reduce inefficiencies in the care-seeking pathway. These observations should inform post-2015 TB strategies and influence policy-making on health services that are meant to be free of charge.

Abstract access 

Editor’s notes: Household health care expenditures can often push households into poverty. These payments, known as catastrophic payments, mean that households are giving up the consumption of basic goods and services to pay for health care.  This study uses individual level data on health care expenditures for TB services and income levels, to examine the extent to which TB involves catastrophic payments in Nigeria.  Although TB services are subsidized and supposed to be free, this survey confirms this is not the case with patients paying most frequently for drugs, laboratory tests and transport.   Of particular concern is the high level of pre-diagnostic costs; that the poor are more vulnerable and the situation is exacerbated for those with HIV co-infection. The findings are important for policy makers trying to improve access to TB care, HIV care and access to health care in general. They emphasize the importance of prepayment schemes to facilitate access to health care when individuals are at their most in need.  

Africa
Nigeria
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Some evidence of impact from external funding for HIV, TB and malaria - and the need for more

Impact of external funding for HIV, tuberculosis and malaria: systematic review.

de Jongh TE, Harnmeijer JH, Atun R, Korenromp EL, Zhao J, Puvimanasinghe J, Baltussen R. Health Health Policy Plan. 2013 Aug 5. [Epub ahead of print]

Background:  Since 2002, development assistance for health has substantially increased, especially investments for HIV, tuberculosis (TB) and malaria control. We undertook a systematic review to assess and synthesize the existing evidence in the scientific literature on the health impacts of these investments.

Methods and Findings:  We systematically searched databases for peer-reviewed and grey literature, using tailored search strategies. We screened studies for study design and relevance, using predefined inclusion criteria, and selected those that enabled us to link health outcomes or impact to increased external funding. For all included studies, we recorded dataset and study characteristics, health outcomes and impacts. We analysed the data using a causal-chain framework to develop a narrative summary of the published evidence. Thirteen articles, representing 11 individual studies set in Africa and Asia reporting impacts on HIV, tuberculosis and malaria, met the inclusion criteria. Only two of these studies documented the entire causal-chain spanning from funding to programme scale-up, to outputs, outcomes and impacts. Nonetheless, overall we find a positive correlation between consecutive steps in the causal chain, suggesting that external funds for HIV, tuberculosis and malaria programmes contributed to improved health outcomes and impact.

Conclusions:  Despite the large number of supported programmes worldwide and despite an abundance of published studies on HIV, TB and malaria control, we identified very few eligible studies that adequately demonstrated the full process by which external funding has been translated to health impact. Most of these studies did not move beyond demonstrating statistical association, as opposed to contribution or causation. We thus recommend that funding organizations and researchers increase the emphasis on ensuring data capture along the causal pathway to demonstrate effect and contribution of external financing. The findings of these comprehensive and rigorously conducted impact evaluations should also be made publicly accessible.

Keywords: Africa, Asia, Health financing, developing countries, donors, health outcomes, impact

Abstract access

Editor’s notes: In the current context of resource constraints and after a decade of unprecedented increases in development assistance for health (particularly for HIV, tuberculosis and malaria), donors are increasingly concerned about the value for money of their investments. This study reviewed available evidence on the impact of external funding, finding a paucity of rigorous scientific evaluation data on the efficiency, effectiveness and impact.

The identified HIV studies found associations between programme investments and increased access and adherence to ART, as well as reduced HIV-related mortality, but limited evidence of preventive impacts on rates of HIV infection. There were many study limitations, including the lack of randomization or robust controls, and relatively small (or statistically insignificant) observed effects. Few studies provided a full analysis of effectiveness along the causal chain from inputs to impact, and none considered the potential undesirable effects of external funding.

Although the aims of the study were ambitious, this paper highlights the challenges of documenting the impacts of financial investments, with the authors arguing that future evaluations need to adopt a more systemic approach to impact evaluation that better captures the causal pathway between investment inputs and impacts, as well as broader system-wide effects. 

Africa, Asia
Cameroon, China, India, Kenya, Malawi, Zambia
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Modelling combination prevention: the importance of joint effectiveness assumptions

Combination HIV Prevention: The Value and Interpretation of Mathematical Models.

Walensky RP, Curr HIV/AIDS Rep. 2013 Jun 25. [Epub ahead of print]

Mathematical models of HIV prevention interventions often provide critical insights related to programmatic design and economic efficiency. One recent dynamic model by Long et al. highlights that a combination prevention approach - with testing, treatment, circumcision, microbicides and PrEP - may decrease transmissions by over 60 % and may be very cost-effective in South Africa. In this analysis, the authors introduce the critical concept of joint effectiveness of preventions programs and demonstrate how some programs operate synergistically (HIV screening coupled with early treatment) while others may create redundancies (microbicides coupled with pre-exposure prophylaxis). Whether combination HIV prevention programs perform with additive, multiplicative or maximal effectiveness will be important to consider in anticipation of their combined transmission impact.

Abstract access

Editor’s notes: This commentary highlights important concepts and results from a recent modelling study of combination prevention for HIV in South Africa. A key concept discussed is that of ‘joint effectiveness’, which considers how two or more intervention programmes, might work together in the same population. While multiplicative effectiveness is often assumed, other options are to optimistically assume additive effectiveness, where distinct, non-interacting parts of the population use and benefit from the different interventions, or to conservatively assume maximal effectiveness, where it is the same individuals who use and/or benefit from all of the interventions, substantially reducing the overall impact. The commentary also highlights the synergies and redundancies found in the study between different intervention components, and illustrates how the discounting of future costs and benefits used in this and other cost-effectiveness studies can affect the relative cost-effectiveness of different interventions depending upon when costs are incurred and benefits accrued. These are all important considerations for future modelling and cost-effectiveness studies looking at combination HIV prevention.

Africa
South Africa
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Aid disbursements to reproductive health stable or slightly increasing

Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010.

Hsu J, Berman P, Mills A. Lancet. 2013 May 18;381(9879):1772-82.

Background: Information is scarce about the extent to which official development assistance (ODA) is spent on reproductive health to provide childbirth care; support family planning; address sexual health; and prevent, treat, and care for sexually transmitted infections, including HIV. We analysed flows of ODA to reproductive health for 2009 and 2010, assessed their distribution by donor type and purpose, and investigated the extent to which disbursements respond to need. We aimed to provide global estimates of aid to reproductive health, to assess the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need.

Methods: We applied a standard definition of reproductive health across all donors, including a portion of disease-specific activities and health systems development. We analysed disbursements to reproductive health by donor type and purpose (e.g., family planning). We also reported on an indicator to monitor donor disbursements: ODA to reproductive health per woman aged 15-49 years. We analysed the extent to which funding is targeted to countries most in need, proxied by female life expectancy at birth and prevalence of HIV infection in adults.

Findings: Donor disbursements to reproductive health activities in all countries amounted to US$5579 million in 2009 and US$5637 million in 2010-an increase of 1.0%. ODA for such activities in the 74 Countdown priority countries increased more rapidly at 5.3%. More than half of the funding was directed towards prevention, treatment, and care of HIV infection for women of reproductive age (15-49 years of age). On average, ODA to general reproductive health activities amounted to 15.9% and ODA to family planning 7.2%. Aid to reproductive health was heavily dependent on the USA, the Global Fund, the UK, the United Nations Population Fund, and the World Bank.

Interpretation: Donors are prioritising reproductive health, and the slight increase in funding in 2009-10 is welcome, especially in the present economic climate. The large share of such funding for activities related to HIV infection in women of reproductive age affects the amount of ODA received by priority countries. It should thus be distinguished from resources directed to other reproductive health activities, such as family planning, which has been the focus of recent worldwide advocacy efforts. Tracking of donor aid to reproductive health should continue to allow investigation of the allocation of resources across reproductive health activities, and to encourage donor accountability in targeting aid flows to those most in need.

Abstract access 

Editor’s notes: This study analyzes the flows of official development assistance (ODA) to reproductive health in the context of the economic crisis. It is the first resource tracking to cover a more comprehensive set of female reproductive health activities, such as family planning and the treatment of sexually treated infections, including HIV. With a 1% increase in real terms, the study highlights the stability of ODA to reproductive health as promising, although the aggregate masks significant fluctuations by certain donors. Claiming more than half the total aid, funding for HIV activities dominates the package, while the 7.2% for family planning is of concern, given recent commitments. The study also finds that ODA disbursements are closely related to need and that this may even be improving slightly – this is encouraging in terms of the efficiency and effectiveness of aid to women’s health priorities.  

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